Amends title XVIII (Medicare) of the Social Security Act and the Age Discrimination in Employment Act of 1967 to provide that employers must offer group health insurance to a non-working spouse who is between the ages of 65 to 70 on the same basis as such insurance is available to those under age 65.
Extends for two years provisions of part B (Supplementary Medical Insurance) of title XVIII which set part B enrollee premiums.
Directs the Secretary of Health and Human Services to establish, under part B of title XVIII, fee schedules for clinical diagnostic laboratory tests except those provided to hospital inpatients.
Directs the Secretary to set the fee schedules at 60 percent (or, in the case of a test performed by a hospital laboratory for outpatients of such hospital, 62 percent) of the prevailing charge level for similar tests for the applicable area.
Provides that when payment is made on the basis of an assignment the Medicare reimbursement shall be 100 percent of the fee schedule amount.
Provides, in other cases, that reimbursement shall be:
(1) 80 percent of the lesser of the amount determined under the fee schedule or the charges billed; or
(2) 100 percent of a negotiated rate which the Secretary is authorized to establish and which is acceptable to the person or entity performing the test.
Directs the Secretary to simplify procedures with respect to claims and payments for clinical diagnostic laboratory tests so as to reduce unnecessary paperwork which assuring that sufficient information is supplied to identify instances of fraud and abuse.
Directs the Comptroller General to report to Congress concerning the fee schedules.
Directs the Secretary to issue revisions to the current guidelines for payment under part B of title XVIII for the transtelephonic monitoring of cardiac pacemakers.
Requires such guidelines to include provisions regarding the specifications for and frequency of transtelephonic monitoring procedures which will be found to be reasonable and necessary.
Provides that, except in special cases where more frequent monitoring is justified, if the guidelines are not in effect by October 1, 1984, and until such guidelines are put into effect, payment may not be made under part B for transtelephonic monitoring procedures, with respect to a single-chamber cardiac pacemaker powered by lithium batteries, more frequently than:
(1) weekly during the first month after implantation;
(2) once every two months during the period representing 80 percent of the estimated life of the implant; and
(3) monthly thereafter.
Directs the Secretary to review and report to Congress concerning the appropriateness of physicians' charges associated with the implantation or replacement of pacemaker leads and devices.
Directs the Prospective Payment Assessment Commission to review and report to Congress regarding hospital payment amounts for implantation and replacement.
Directs the Secretary, through the Commissioner of the Food and Drug Administration, to provide for a registry of all cardiac pacemaker devices and leads for which Medicare payment was made.
Eliminates special payment provisions for preadmission diagnostic testing.
Limits the Medicare physician reasonable charge level and prevailing charge level, for the 15 month period beginning July 1, 1984, to a level that is not higher than the level set for the 12-month period beginning July 1, 1983.
Permits any physician or supplier to voluntarily enter into an agreement with the Secretary to become a "participating physician or supplier." States that a "participating physician or supplier" is one who will accept payment on the basis of an assignment.
Directs the Secretary to publish annually:
(1) a directory of all participating physicians and suppliers; and
(2) a list containing the percent of claims submitted with respect to each physician and supplier that was paid on the basis of an assignment.
Directs the Secretary, in the case of a physician, to monitor the physician's charges for the 15-month period beginning July 1, 1984, and authorizes the Secretary to apply sanctions against a nonparticipating physician if such physician knowingly and willfully bills Medicare enrollees for actual charges in excess of such physician's actual charges for the calendar quarter beginning on April 1, 1984.
Directs the Secretary:
(1) during the 15 month period, to monitor physicians' services in order to determine any changes in the per capita volume and mix of physicians' services provided to beneficiaries under part B of title XVIII, classified by participating and nonparticipating physicians, by assigned and nonassigned claims, by specialty, and by geographic area;
(2) to report to Congress concerning the monitoring; and
(3) to include recommendations in the report as to how to limit part B program costs without burdening part B beneficiaries.
Provides for the transfer from the Federal Supplementary Medical Insurance Trust Fund of funds for FY 1984 and 1985, in addition to other funds available for such fiscal years, for payments to implement this paragraph.
Provides that if all of the teaching physicians in a hospital agree to have payment made for all their part B patients on the basis of an assignment, the payment rate shall be 90 percent of the prevailing charge.
Revises the formula for determining customary charges for teaching physicians to provide that the customary charges cannot be less than 85 percent of the prevailing charge.
Directs the Comptroller General to conduct a study of and report to the appropriate House and Senate committees concerning teaching physicians' charges.
Directs the Secretary to issue regulations which require, for purposes of title XVIII, that providers of services calculate and report the lesser of cost or charges determinations separately with respect to payments for services under part A (Hospital Insurance) and part B of title XVIII (other than clinical diagnostic laboratory tests), and that payment under title XVIII be based upon such separate determinations.
Provides that charges representing 60 percent or less of costs shall be considered nominal for purposes of applying the nominality test under parts A and B with respect to services furnished by a public provider free of charge or at a nominal costs.
Directs the Director of the Office of Technology Assessment to conduct a study of physician reimbursement under the Medicare program and to report to Congress on such study.
Directs the Secretary, in order to assist the Director in completing the study and facilitate congressional review, to compile a centralized Medicare part B charge data base.
Revises provisions relating to the target rate reimbursement system which limits the increase in Medicare hospital costs per case by substituting "one-quarter of one percentage point" for "one percentage point" in the formula for determining the applicable percentage increase.
Permits a hospital which is classified as a rural hospital to appeal to the Secretary for classification as a rural referral center on the basis of criteria established by the Secretary which allow the hospital to demonstrate that it should be so reclassified because certain of its operating characteristics are similar to those of a typical urban hospital located in the same census region.
Directs the Secretary to publish the criteria, not later than 30 days after the date of the enactment of this Act, for implementation by October 1, 1984.
(1) a hospital located in a Metropolitan Statistical Area (MSA) shall be deemed to be located in the region in which the majority of the hospitals in the same MSA are located, or, at the option of the Secretary, the region in which the majority of Medicare inpatient discharges from hospitals in the same MSA are located; and
(2) a hospital reclassified under clause
(1) shall not have its Medicare payments reduced for discharges occurring before October 1, 1984.
Directs the Secretary to conduct a study of:
(1) the distinction between urban and rural hospitals for purposes of the Diagnosis Related Group (DRG) payment provisions and the effect which such distinction may have on rural hospitals in the case of those DRGs which have high fixed nonlabor components which do not vary significantly between urban and rural areas;
(2) the advisability and feasibility of varying by DRG the proportions of the labor and nonlabor components of the Federal payment amount instead of applying those components to all DRGs; and
(3) further refinements which may be appropriate in the inpatient hospital prospective payment provisions of title XVIII in order to address the problems of differences in payment amounts to specific hospitals.
Requires the results of such studies to be reported to Congress. Provides for payment to a hospital on the basis of reasonable cost for the costs incurred by such hospital for anesthesia services provided by a certified registered nurse anesthetist.
Directs the Secretary to conduct a study of possible methods of reimbursement under Medicare which would not discourage the use of certified registered nurse anesthetists by hospitals.
Provides for an Executive Director of the Prospective Payment Assessment Commission. Authorizes the Secretary, in order to supplement the activities of the Commission, to carry out or award grants or contracts for original research and experimentation.
Provides that in establishing an appropriate allowance for depreciation under Medicare and for interest on capital indebtedness and a return on equity capital with respect to an asset of a hospital or skilled nursing facility which has undergone a change of ownership, the valuation of the asset after such change shall be the lesser of the allowable acquisition cost of such asset to the first owner of record on or after the enactment of this paragraph or the acquisition cost of such asset to the new owner.
Requires a State's Medicaid program (title XIX of the Social Security Act) to provide assurances that the payment methodology utilized by the State's Medicaid program for payments to hospitals, skilled nursing facilities, and intermediate care facilities can reasonably be expected not to increase such payments solely as a result of a change of ownership in excess of the increase which would result from the application of the previous sentence.
Directs the Secretary to:
(1) conduct a study to develop an appropriate wage index for hospital workers;
(2) report the results to Congress; and
(3) adjust hospital payments under Medicare as necessary.
Directs the Secretary to conduct a study and report to Congress proposed criteria under which the Secretary would make adjustments for certain hospitals' discharges to more accurately reflect the discharges.
Specifies a deadline of July 1, 1985, for a report to Congress on including payment for physicians' services to hospital inpatients in DRG payment amounts.
Defines the term "bona fide emergency services" as used in title XVIII. Prohibits the Secretary, in determining Medicare payment amounts with respect to routine service costs of extended care services for cost reporting periods beginning on or after July 1, 1984, from recognizing as reasonable per diem costs for such services costs exceeding:
(1) for free-standing facilities in rural and urban areas, 112 percent of the mean per diem routine service costs for free-standing skilled nursing facilities located in rural and urban areas; and
(2) for hospital-based skilled nursing facilities located in rural and urban areas, the limit for free-standing skilled nursing facilities (located in rural and urban areas), plus 50 percent of the amount by which 112 percent of the mean per diem routine service costs for hospital-based skilled nursing facilities (located in rural and urban areas) exceeds the limit for freestanding skilled nursing facilities located in rural and urban areas.
Directs the Secretary to submit to Congress, prior to December 1, 1984:
(1) the report required by the Social Security Amendments of 1983 relating to skilled nursing facilities; and
(2) a report on the range of options for prospective payment of skilled nursing facilities under Medicare. Directs the Secretary to report to the appropriate House and Senate committees, prior to August 1, 1984, proposals required under part A (General Provisions) of title XI of the Social Security Act for prospective reimbursement of skilled nursing facilities.
Permits payments to a hospital under part A of Medicare for the operation of mobile intensive care units if certain conditions are met.
Requires the hospital to be a statewide demonstration project hospital located in New Jersey and requires the project to provide for payments to hospitals in the State on a prospective basis related to a classification of patients by diagnosis related groups.
Limits payment to home health agencies for durable medical equipment to a maximum of 80 percent of the reasonable cost of the equipment, except for equipment furnished free of charge by a public home health agency.
Defines the term "durable medical equipment." Provides for the coverage, as medical and other health services, of the services of a clinical psychologist furnished pursuant to a risk-sharing contract with a health maintenance organization or a competitive medical plan.
Provides for coverage of hepatitis B vaccine and its administration when furnished to an individual who is at high or intermediate risk of contracting hepatitis B. Provides for the coverage, as medical and other health services, of blood clotting factors for hemophilia patients competent to use such factors to control bleeding without medical or other supervision and items related to the administration of such factors.
Directs the Secretary to prohibit payment for a physician's debridement of mycotic toenails if performed more than once every 60 days, unless the physician documents the necessity for such treatment.
Allows the Secretary, during FY 1985 to 1986, to enter into not more than two competitively bid contracts with Medicare intermediaries and carriers under part A of Medicare and two under part B (Supplementary Medical Insurance) of Medicare. Permits the Secretary to employ competitive bidding without regard to the nominating process only to replace an intermediary or carrier which over a period of time has been in the lowest 20th percentile of organizations having contracts.
Directs the Secretary, by July 1, 1987, to limit to no more than ten the number of regional intermediaries for home health agencies.
Directs the Secretary, in determining the necessary and proper cost of administration for carriers and intermediaries, to take into account their reasonable and adequate costs.
Directs the Comptroller General to conduct a study on and report to Congress concerning Medicare claims processing.
Removes the prohibition, under part A (General Provisions) of title XI of the Social Security Act, on making research and demonstration grants to for-profit organizations.
Provides that the Administrator of the Health Care Financing Administration shall be appointed by the President by and with the advice and consent of the Senate. Authorizes the Secretary to bar from participation in Medicare or Medicaid any provider of which five percent or more is owned by an individual convicted of Medicare or Medicaid related crimes.
Provides for provider representation in peer review organizations.
Repeals specified requirements relating to coverage of tuberculosis treatments under Medicare and Medicaid (title XIX of the Social Security Act.) Permits a physician who has a financial interest in an agency which is a sole community home health agency to carry out the certification and plan-of-care functions for patients who will receive services from the agency.
Provides that payroll taxes shall be transferred from the Treasury to the Federal Hospital Insurance Trust Fund from time to time.
Waives the Medicare part B delayed enrollment penalty and provides a special enrollment period for working individuals aged 65 to 69 who were enrolled in private health plans.
Permits part B Medicare payments to be made to an entity:
(1) which provides coverage of the service under a health benefits plan;
(2) which has paid the person who provided the service the amount which that person has accepted as payment in full for the service; and
(3) to which the individual has agreed in writing that payment may be made.
Revises provisions relating to the accreditation of psychiatric hospitals and psychiatric units of general hospitals with respect to Medicare and Medicaid participation.
Includes podiatrists in the definition of "physician" for purposes of outpatient physical therapy services.
Includes podiatrists and dentists in the definition of "physician" for outpatient ambulatory surgery purposes.
Allows physical therapists to establish Medicare qualified plans for physical therapy.
Authorizes the Secretary to waive certain nursing care requirements for hospices located in rural areas which were in operation on or before January 1, 1983, and have demonstrated a good faith effort to hire enough nurses.
Directs the Secretary to study and report to Congress on the necessity and appropriateness of the requirements that certain core services be furnished directly by a hospice.
Authorizes the United States to bring an action directly against third party insurance programs for Medicare costs.
Prohibits the Secretary from disclosing any accreditation survey made and released to the Secretary by the Joint Commission on Accreditation of Hospitals, the American Osteopathic Association, or any other national accreditation body, of any entity accredited by such body.
Extends the Secretary's authority to rely on accrediting organizations in determining whether rural health clinics, laboratories, clinics, rehabilitation agencies, including outpatient rehabilitation facilities, psychiatric hospitals, and public health agencies meet Medicare requirements.
Requires a hospital, for purposes of Medicare, to maintain an agreement with a professional standards review organization or with a utilization and quality control peer review organization.
(Current law requires only an agreement with a utilization and quality control peer review organization.) Provides that coverage for the services of a home health agency or hospice shall end 30 days following the termination of the home health agency's or hospice's Medicare participation agreement.
Eliminates the Health Insurance Benefits Advisory Council. Directs the Secretary to establish a single 30-day period in which all of the competitive medical plans (CMP) and health maintenance organizations (HMO) in an area participating in Medicare must have an open enrollment period.
Authorizes the Secretary to phase in the provision of the previous sentence over a three year period.
Permits an HMO or a CMP to withhold and reserve a part of the value of the additional benefits required to be furnished to enrollees for use in subsequent contract periods.
Provides that providers, with respect to hearings before the Provider Reimbursement Review Board, shall have the right to obtain judicial review of any action of a fiscal intermediary which involves a question of law or regulations relevant to the matters in controversy whenever the Provider Reimbursement Review Board determines that it is without authority to decide the question, by a civil action commenced within 60 days of the date on which notification of such determination is made.
Authorizes the Secretary, if patient health and safety is not jeopardized, to apply less severe sanctions than are presently available for dealing with an end-stage renal disease facility which is not in compliance with applicable regulations.
Directs the Secretary to carry out a study and report to Congress with respect to payments to promote the closure and conversion of under utilized hospital facilities.
Makes miscellaneous technical corrections to Medicare provisions.
Requires the Secretary to approve certain waivers for projects demonstrating the concept of a social HMO. Requires the Secretary to report to Congress concerning the projects.